Tuberculosis is an acute or chronic infection caused by Mycobacterium tuberculosis. TB is characterized by pulmonary infiltrates, formation of granulomas with caseation, fibrosis, and cavitation. People living in crowded and poorly ventilated conditions and who are immunocompromised are most likely to become infected. In the United States, incidence is higher among the homeless, drug-addicted, and impoverished populations, as well as among immigrants from or visitors to countries in which TB is endemic. In addition, persons at highest risk include those who may have been exposed to the bacillus in the past and those who are debilitated or have lowered immunity because of chronic conditions such as AIDS, cancer, advanced age, and malnutrition. When the immune system weakens, dormant TB organisms can reactivate and multiply.
When this latent infection develops into active disease, it is known as reactivation TB, which is often drug resistant. Multidrug-resistant tuberculosis (MDR-TB) is also on the rise, especially in large cities, in those previously treated with antitubercular drugs, or in those who failed to follow or complete a drug regimen. It can progress from diagnosis to death in as little as 4–6 weeks. MDR tuberculosis can be primary or secondary. Primary is caused by person-to-person transmission of a drug-resistant organism; secondary is usually the result of nonadherence to therapy or inappropriate treatment.
Nursing Care Plans
- Risk for Infection
- Ineffective Airway Clearance
- Risk for Impaired Gas Exchange
- Imbalanced Nutrition: Less Than Body Requirements
- Deficient Knowledge
- Other Possible Nursing Care Plans
Ineffective Airway Clearance
May be related to
- Thick, viscous, or bloody secretions
- Fatigue, poor cough effort
- Tracheal/pharyngeal edema
Possibly evidenced by
- Abnormal respiratory rate, rhythm, depth
- Abnormal breath sounds (rhonchi, wheezes), stridor
- Maintain patent airway.
- Expectorate secretions without assistance.
- Demonstrate behaviors to improve/maintain airway clearance.
- Participate in treatment regimen, within the level of ability/situation.
- Identify potential complications and initiate appropriate actions.
|Assess respiratory function noting breath sounds, rate, rhythm, and depth, and use of accessory muscles.||Diminished breath sounds may reflect atelectasis. Rhonchi, wheezes indicate accumulation of secretions and inability to clear airways that may lead to use of accessory muscles and increased work of breathing|
|Note ability to expectorate mucus and cough effectively; document character, amount of sputum, presence of hemoptysis.||Expectoration may be difficult when secretions are very thick as a result of infection and/or inadequate hydration. Blood-tinged or frankly bloody sputum results from tissue breakdown (cavitation) in the lungs or from bronchial ulceration and may require further evaluation or intervention.|
|Place patient in semi or high-Fowler’s position. Assist patient with coughing and deep-breathing exercises.||Positioning helps maximize lung expansion and decreases respiratory effort. Maximal ventilation may open atelectatic areas and promote movement of secretions into larger airways for expectoration.|
|Clear secretions from mouth and trachea; suction as necessary.||Prevents obstruction and aspiration. Suctioning may be necessary if patient is unable to expectorate secretions.|
|Maintain fluid intake of at least 2500 mL/day unless contraindicated.||High fluid intake helps thin secretions, making them easier to expectorate.|
|Humidify inspired air and oxygen||Prevents drying of mucous membranes and helps thin secretions.|
|Administer medications as indicated:|
||Reduces the thickness and stickiness of pulmonary secretions to facilitate clearance.|
||Increases lumen size of the tracheobronchial tree, thus decreasing resistance to airflow and improving oxygen delivery.|
||May be useful in presence of extensive involvement with profound hypoxemia and when inflammatory response is life-threatening.|
|Be prepared for/assist with emergency intubation.||Intubation may be necessary in rare cases of bronchogenic TB accompanied by laryngeal edema or acute pulmonary bleeding.|
Recommended nursing diagnosis and nursing care plan books and resources.
- Nursing Care Plans: Nursing Diagnosis and Intervention (10th Edition)
An awesome book to help you create and customize effective nursing care plans. We highly recommend this book for its completeness and ease of use.
- Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions and Rationales
A quick-reference tool to easily select the appropriate nursing diagnosis to plan your patient’s care effectively.
- NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023 (12th Edition)
The official and definitive guide to nursing diagnoses as reviewed and approved by the NANDA-I. This book focuses on the nursing diagnostic labels, their defining characteristics, and risk factors – this does not include nursing interventions and rationales.
- Nursing Diagnosis Handbook, 12th Edition Revised Reprint with 2021-2023 NANDA-I® Updates
Another great nursing care plan resource that is updated to include the recent NANDA-I updates.
- Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM))
Useful for creating nursing care plans related to mental health and psychiatric nursing.
- Ulrich & Canale’s Nursing Care Planning Guides, 8th Edition
Claims to have the most in-depth care plans of any nursing care planning book. Includes 31 detailed nursing diagnosis care plans and 63 disease/disorder care plans.
- Maternal Newborn Nursing Care Plans (3rd Edition)
If you’re looking for specific care plans related to maternal and newborn nursing care, this book is for you.
- Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care (7th Edition)
An easy-to-use nursing care plan book that is updated with the latest diagnosis from NANDA-I 2021-2023.
- All-in-One Nursing Care Planning Resource: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health (5th Edition)
Definitely an all-in-one resources for nursing care planning. It has over 100 care plans for different nursing topics.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other nursing care plans related to respiratory system disorders:
- Asthma | 8 Care Plans
- Bronchiolitis | 5 Care Plans
- Bronchopulmonary Dysplasia (BPD) | 5 Care Plans
- Chronic Obstructive Pulmonary Disease (COPD) | 7 Care Plans
- Cystic Fibrosis | 5 Care Plans
- Hemothorax and Pneumothorax | 3 Care Plans
- Influenza (Flu) | 5 Care Plans
- Lung Cancer | 5 Care Plans
- Mechanical Ventilation | 6 Care Plans
- Near-Drowning | 5 Care Plans
- Pleural Effusion | 6 Care Plans
- Pneumonia | 11 Care Plans
- Pulmonary Embolism | 4 Care Plans
- Pulmonary Tuberculosis | 5 Care Plans
- Tracheostomy | 5 Care Plans